role of laparoscopy on fertility

1. DR SUNDAR NARAYANAN M.D, FICS
DIP LAP (GER), DIP MIS (FRA),
DIP ART (ISR), DIP US (CRA)

2.  One of the commonest surgical procedure
performed for fertility enhancement
 Almost 40 percentage of patients undergo DHL
during fertility workup
 With the advent of high quality instruments
and advanced operative techniques laparotomy
as a choice for fertility management is done
only on exceptional conditions

3.  With recent improvements in ART techniques
there is a growing tendency that bypasses
DHL procedure and proceeds directly to ART.
 So routine use of DHL as evaluation for all
cases of female fertility is presently under
debate.
 ? Role of laparoscopy in the present scenario.

5.  Controlled Ovulation induction with or
without IUI still remains the first line of
management in case of PCOS.
 Diet, life style modifications and insulin
sensitizers play a major adjuvant role in
management of PCOS
 LOD should be considered in cases of failed
COI with IUI.

6.  Lean PCOS women (BMI ≤25 kg/m2) achieved
higher conception rates than overweight
women Duleba et al 2003
 PCOS women with BMI ≥35 kg/m2 achieved
significantly lower ovulation and pregnancy
rates after LOD compared with normal weight
women.

7.  Lower pre-treatment LH levels or a lower
LH/FSH ratio were more likely to benefit from
the treatment for a longer period compared
with those who had higher pre-treatment levels
as they are more likely to experience early
recurrence of their anovulatory status.
 Women with a duration of infertility >3 years
were less likely to respond to LOD. Li et al 1998

8.  According to Cochrane review LOD is as
effective as gonodotrophins in women with
clomiphene resistant PCOS.
 Reduction in multiple pregnancy rates
compared to gonadotrophins make this option
attractive
 Over enthusiastic and repeated LOD’s should
be avoided as there are concerns of long term
effect on ovarian function

9.  Research has not firmly proved that removing
mild endometriosis improves fertility as the two
major studies report conflicting results(ACOG
Practice Bulletin 2010)
 For moderate to severe endometriosis surgery will
improve your chances of pregnancy (ASRM
committee opinion 2012)
 Optimal laparoscopic treatment requires not only
surgical skill, but also comprehensive knowledge
of pelvic anatomy and a good understanding of
endometriosis and its progression.

10.  Large endometriomas may need to be
removed surgically prior to IVF but smaller
ones are generally best left in place.
 Surgery for very severe endometriosis or repeat
surgery is generally not beneficial and may
cause harm by reducing ovarian reserve and
these patients better respond to ART. (ASRM
committee opinion 2012)

11.  Two RCT’S on patients with mild to moderate
endometriosis
 Meta analysis demonstrated an advantage of
laparoscopic surgery in terms of clinical
pregnancy and live birth rate.
 Use of laparoscopic surgery in the treatment of
sub fertility related to mild to moderate
endometriosis may improve future fertility
(Cochrane review 2009)

12.  Analysis of the epidemiologic data drawn
mainly from comparative studies and cohorts,
shows that the role of cysts in infertility is
controversial.
 The effects of surgical treatment are often more
harmful than the cyst itself to the ovarian
reserve.
 Surgery is indicated only in case of large cysts
with associated potential complications.

13.  When a surgical option is nonetheless chosen a
conservative laparoscopic approach is more
suitable.
 while performing surgery the context of the
infertility is essential, and surgeons and
specialists in reproductive medicine should
decide management jointly. (American Society
for Reproductive Medicine 2014)

14.  Nine RCT’s on lap Vs laparotomy
 Three RCT’s on lap vs minilaparotomy
 One study on cost effectiveness
 Laparoscopy for benign ovarian tumours is
associated with reduced post operative pain
and complications and better fertility outcome
due to reduced post operative adhesions and is
cost effective (Cochrane review 2009)

15.  Fertility outcomes are decreased in women with
sub mucosal and deeply infiltrating intramural
fibroids and warrant consideration of
myomectomy in the subfertile patient. (Curr
opin obstet gynecol 2013).
 Intramural fibroids appear to decrease fertility
with an increased risk of spontaneous
miscarriage but the results of therapy are
unclear. Myomectomy may be considered
before ART to alleviate these detrimental
effects. (womens health lond engl 2009).

16.  Studies have demonstrated that subserosal
fibroids did not negatively impact fertility.
 Laparoscopic myomectomy is a feasible
technique safe for patients waiting for
conception and has proven its interest in case
of infertility. (Gynecol Obstet Biol Reprod Paris
2007)

17.  Although there is a risk of uterine rupture
following laparoscopic myomectomy, when
performed by an experienced surgeon, can be
considered a safe technique with an extremely
low failure rate and good results in terms of the
outcome of pregnancy.(J Gynecol Endosc Surg.
2011)

18.  One study on reproductive outcome and two
RCT’s on open Vs laparoscopic approach
 No significant effect of myomectomy on
reproductive outcome and no significant
differences between two modalities of treatment
 This evidence needs to be viewed with caution
due to small number of studies and no RCT to
evaluate the role of myomectomy to improve
fertility (Cochrane review 2012)

19.  The overall pregnancy rate after successful
hysteroscopic proximal cannulation of at least one
tube is 55%.
 The mean time to become pregnant after successful
unilateral or bilateral hysteroscopic cannulation
was 10.5 ± 8.9 months.
 Laparo hysteroscopic cannulation for proximal
obstruction is a procedure with minimal morbidity
and a reasonable successful recanalisation rate. It
should be considered as an alternative to in vitro
fertilisation. (ANZJOG © 2012)

20.  Canadian Task Force Clinical cases series of 168
women with a proximal tubal block, the successful
recanalization rate was 54.2% per tube and 61.9% per
patient
 Cumulative conception rate was 43.7% at 2 years and
for patients with unilateral obstruction is 60.7% .
 Successful tubal cannulation led to significant
improvement in the pregnancy rate in these women
and laparoscopy guided hysteroscopic cannulation is
still a viable alternative to in vitro fertilization.
(AAGL 2014).

21.  Five RCT’s involving 646 women on
salphingectomy, tubal occlusion, aspiration Vs
no treatment.
 Clinical and ongoing pregnancy rates increased
with salphingectomy prior to IVF
 Tubal occlusion increases clinical but not
ongoing pregnancy rate
 Effect of US guided aspiration is doubtful and
needs to be assessed. (Cochrane 2010)

22.  Seventy-nine ampullary tubal ectopic
pregnancies were managed using laparoscopic
linear salpingostomy
 62% conceived following salpingostomy with
a live birth rate of 38 %.
 Skilled laparoscopist can remove a small tubal
pregnancy in this manner with minimal
complications. (Obstet Gynecol 1987)

23.  Systemic methotrexate and laparoscopic
salpingostomy were successful in treating the
majority of cases with no significant difference
between the treatments in the homolateral
patency rate (Lancet 1997)

24.  In the surgical treatment of tubal ectopic
pregnancy laparoscopic surgery is a cost
effective treatment.
 An alternative nonsurgical treatment option in
selected patients is medical treatment with
systemic methotrexate.
 Expectant management not adequately
evaluated yet. (Cochrane Database Syst
Rev 2007)

25.  Meta-analysis shows that laparoscopic surgery
is the most cost-effective treatment for tubal
EP. Systemic MTX is a good alternative in
selected patients with low serum hCG
concentrations.( Hum Reprod Update 2008)

26.  Laparoscopic tuboplasty, when performed by
experienced surgical laparoscopists, represents
an effective alternative to microsurgery (Fertil
Steril 1991)
 Laparoscopic tubal anastomosis is a highly
successful procedure. This less invasive
approach could be considered the procedure of
choice in patients who desire reversal of tubal
sterilization. (Fertil Steril 1999)

27.  All cases with laparoscopic tubal sterilization
were suitable, whereas all cases with
fimbriectomy were unsuitable for
recanalization.
 In cases with sterilization by Pomeroy's
method, 4 out of 10 (40%) conceived, whereas
for laparoscopic tubal ligation cases 6 out of 7
(85.7%) conceived (P=0.32) (J Hum Reprod
Sci. 2011)

28.  Laparoscopically sterilized patients had better
chances of conception (50 %) following reversal
than those who were sterilized by Pomeroy's
method (30 %). With post-reversal tubal length
of >4 cm, pregnancy rate was 50 %. Isthumus-
Isthumus and Isthumus-Ampullary
anastomosis have 50 % success rates. (J Obstet
Gynaecol India. 2012)

29.  Laparoscopy may be omitted in women with
normal HSG as it was not shown to change the
original treatment plan as indicated by HSG in
95 % of patients (Lavy et al 2004)
 In some specific clinical settings solid evidence
is available to recommend the use of diagnostic
laparoscopy in current fertility practice (Hum
reprod update 2007)

30.  80.7 % of patients after normal HSG revealed
pathologic abnormalities and because of the
potential diagnostic and therapeutic benefits
patients with unexplained infertility should
undergo DHL prior to ART. (Tsuji et al 2009)
 Hystero laparoscopy is an effective diagnostic
& corrective tool for pathologies like peritoneal
endometriosis, adnexal adhesions, and
subseptate uterus which are usually missed by
other imaging modalities.(J Hum reprod 2013)

31.  Review of 495 patients
 21 % of patients had abnormalities which was
treated by laparoscopic intervention followed
by IUI
 4% of patients advised IVF because of severe
abnormalities.
 DHL altered treatment decisions in high
number of patients and may be of considerable
value and further RCT’s are needed to asses its
cost effectiveness (Fertil Steril 2003)

32.  One randomized and five non-randomized
controlled studies including a total of 3179
participants were included comparing
hysteroscopy with no intervention in the cycle
preceding the first IVF cycle
 Significantly higher clinical pregnancy rate
(relative risk, RR, 1.44, 95% CI 1.08-1.92,
P=0.01) and LBR (RR 1.30, 95% CI 1.00-1.67,
P=0.05) in the subsequent IVF cycle in the
hysteroscopy group

33.  Hysteroscopy in asymptomatic woman prior to
their first IVF cycle was found to be associated
with improved chance of achieving a
pregnancy and live birth
 Robust and high-quality randomized trials to
confirm this finding are warranted (Reprod
Biomed Online 2014)

34.  Laparoscopic ovarian drilling results, at least
in equal pregnancy rates as gonadotropin
treatment (RR 1.0, 95% CI 0.83-1.2) added
benefit being decreased multiple pregnancy
rate (RR 0.16, 95% CI 0.04-0.58).
 The laparoscopic treatment of minimal
endometriosis might increase the pregnancy
rate but the two major studies report
conflicting results.

35.  Laparoscopic surgery in the treatment of sub
fertility related to mild to moderate
endometriosis may improve future fertility
 Excision of the endometriotic cyst wall
increases the spontaneous conception rate (RR
2.8, 95% CI 1.4-5.5) but caution to be exercised
to preserve ovarian reserve.

36.  Myomectomy for submucosal fibroids results
in higher pregnancy rates (RR 2.2, 95% CI 1.6-
2.9).
 The removal of intramural/ subserosal fibroids
shows a beneficial trend, albeit not statistically
significant results (RR 1.2, 95% CI 0.75-1.9).

37.  Laparoscopy for benign ovarian tumors when
chosen offers better fertility outcome and is
cost effective
 For proximal tubal block laparoscopy guided
hysteroscopic cannulation is still a viable
alternative to in vitro fertilization.

38.  Laparoscopic surgery is the most cost-effective
treatment for tubal ectopic pregnancy and
Systemic methotrexate is a good alternative in
selected patients
 Laparoscopic tubal anastomosis is a highly
successful procedure and laparoscopically
sterilized patients had better chances of
conception

39.  Removal of polyps prior to IUI increases the
pregnancy rate (RR 2.2, 95% CI 1.6-3.1).
 Laparoscopic tubal surgery for hydrosalpinx
prior to IVF increases the pregnancy rate (RR
1.9, 95% CI 1.4-2.7).
 Hysteroscopy in patients with recurrent IVF
failure increases the pregnancy rates even in
the absence of pathology (RR 1.6, 95% CI 1.3-
1.9).

40.  Hystero laparoscopy may be an effective
diagnostic & corrective tool in cases of
unexplained infertility
 DHL may be of considerable value before
commencing IUI and further RCT’s are needed
to asses its cost effectiveness
 Hysteroscopy prior to IVF improves chances of
pregnancy and randomized trials are required
to confirm this finding.

41.  Laparoscopy still remains an important
diagnostic ant therapeutic tool in the
management of sub fertile women.
 Optimal and prudent use of this minimally
invasive technique may avert costly treatment
like IVF but over zealous and unindicted use
may compromise future fertility

42.  Although the limited evidence indicates a
positive role for some surgical reproductive
interventions, we should be very cautious in
providing guidelines for clinical practice in
reproductive surgery since more research is
needed.(cochrane 2011)